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Improving efficiency in cancer care: a multidisciplinary challenge 

A joint ESO-SPCC task-force met to design a strategy to help different actors involved in cancer care to optimise patient journey, tackling challenges from different points of view. 

“I think the focus here is not about having something new, but how to use what we have in a better way”. With these words Matti Aapro, European School of Oncology (ESO), Sharing Progress in Cancer Care (SPCC) and European Cancer Organization (ECCO), Genolier (CH) opened a meeting dedicated to one of the hottest topics in cancer care: how to improve efficiency. The meeting was held in Italy (Inveruno, Milan area) and was supported by an unrestricted grant from Bristol- Myers Squibb (BMS). Despite the topic of efficiency in cancer care having already been tackled in some position papers, concrete European actions to attain identified goals are still missing. “Therefore, SPCC – presently a division of ESO, and as of 2020 a legally independent not for profit Swiss law-based association – has decided to partner with various stakeholders to develop a plan of action”, Aapro said. The meeting gave the opportunity to each member of the multidisciplinary task-force to share her/his ideas on efficiency in cancer care and to contribute to take the final of unmet needs in the field.

Many cards on the table

No doubt that before starting to draw any educational programme on a topic, it is mandatory to have a clear definition of the problem to better identify both unmet needs and effective solutions. The same applies to the term “efficiency” in cancer care which could be addressed from different points of view, depending on the specific meaning each actor involved in the field is thinking about.

“Listening to different voices, it seems that it is not easy to have a global approach to the concept of efficiency in cancer care”, said Pietro Presti, European Cancer Patient Coalition (ECPC), Turin (IT), co-chair of the meeting. A multifaceted scenario, in fact, emerged during the initial discussion among the members of the task-force, who were asked to lay their cards on the table and explain their idea of efficiency in cancer care. The “circular” journey for patients that often go back and forth between hospitals before the right diagnosis is just one of the several inefficiencies mentioned, together with the underestimated importance of the role of nurses and pharmacists, and the missed opportunity to engage patients as experts that can give a different perspective in the decision-making process. Last but not least, as highlighted by Rosanna Tarricone, Bocconi University, Milan (IT) both economic and management issues need to be addressed to create a successful educational programme and reduce inefficiency – or improve efficiency – in cancer care. At the end of the day, it’s a multidisciplinary exercise, that should strongly connect the concept of efficacy to those of safety and quality and should focus on the overall picture and a joint effort of different professionals and stakeholders.

Learning from what’s on: the PROCHE program example

“Perception is not just a product of the stimulus, but also of mental activity — that we see with the mind as well as the eye”, wrote John F. Kihlstrom, Professor Emeritus in the Department of Psychology at the University of California, Berkeley. What about perception in the cancer care continuum? As reminded during the meeting by Florian Scotté, Hospital Foch, Suresnes (FR) (moving to Institut Gustave-Roussy, Villejuif, France ), co-chair of the meeting, there’s a gap in perception between physicians and patients, when it comes to describing drug-related side effects or other measures of the cancer care process. The issue of differences in perception also emerged from a recent international survey led by researchers from Bocconi University, Milan, showing a mobile health divide between clinicians and cancer patients. “We definitely need to take this in to account in our multidisciplinary programmes”, Scotté stated, underlining the importance of discussing approaches not limited to hospitals, but also reaching patients at home. Monitoring of patients, in fact, improves cancer course and leads to better survival and Quality of Life (QoL), as previously published. “Oncology is changing rapidly and we need new tools and strategies to tackle efficiency/optimization issues”, he said, describing a programme already in place in France to monitoring patients at home. The main aim of the PRogramme of Optimisation of ChemotHErapy administration (PROCHE) is the anticipation of drug delivery and evaluation of the toxicity profile by a medical call centre dedicated to the oncology unit (Figure 1).

Figure 1. The PROCHE programme

 

It seems all about monitoring patients at home, but the programme has been shown to have a broader impact and to be able to optimize the Day Hospital Journey by halving waiting time and nurse care prior infusion, reducing hospitalizations and length of stay, and ameliorating QoL. Just through reorganization, PROCHE has led to improved safety and decreased drug waste (5,4% vs 10% in Day Hospitals with and without PROCHE, respectively). “Some hurdles and educational needs are still to be fixed, but the programme could be implemented in different steps of the cancer care continuum”, Scotté concluded.

Trained nurses as pillars in cancer care

Several studies and, most of all, the real-life experience suggest that effective cancer care can’t do without a multidisciplinary team of health care professionals. Oncology nurses must be part of this team, helping improve the patient’s journey and efficiency in cancer care. “Nursing care can be as effective as physician delivered care and overall is cost-effective with a positive impact on patients’ QoL, reduction of disease burden and hospital admissions”, said Andreas Charalambous, European Oncology Nursing Society (EONS) President, Limassol (Cyprus), focusing the attention to education. According to the expert, education and qualification are essential to effectiveness and efficiency and specialist cancer nursing education can lead to better use of nurses’ skills and more efficient care. Moreover, the key role of a well-educated cancer nurse come to light in every step of the cancer care continuum, from prevention to survivorship. “Based on this background, a programme to improve efficiency in cancer care should include nurses and make a strong and comprehensive educational effort”, Charalambous added, presenting, as an example, the 8-module EONS Cancer Nursing Educational Framework (Figure 2).

Figure 2. The EONS EONS Cancer Nursing Educational Framework. Module 3, Cancer treatment, Patient and Occupational Safety, includes elements of safety, quality and efficiency, fits better on the efficiency topic and can be implemented with more efficiency inputs.

 

Compliance? Ask your pharmacist

Who can help fill in the huge gap in managing cancer treatments and their side-effects between hospital and ambulatory/home care? “The pharmacist” is the right answer according to Alain Astier, Co-President European Society Oncology Pharmacy (ESOP), Henri Mondor University Hospital, Créteil, France. “As cancer is becoming a chronic disease, with almost all cancer treatments based on drugs, onco-pharmacists are of pivotal importance towards proper treatments of patients inside and outside the hospital and, consequently, to improve efficiency in cancer care”, he explained. As a matter of fact, pharmacists have the skills needed to optimize pharmacological treatments and are often the most accessible health care practitioner for patients. They can check and validate prescriptions, share relevant drug information with the care team, improve patients’ QoL and counsel them on posology or side effects. “Giving adequate patient counselling to improve compliance is definitely one of the main responsibilities of pharmacists”, Astier added, reminding that poor compliance is the reason behind the lack of clinical effects from many cancer therapies. Programmes like ONCOLIEN, developed by the French Society of Oncology Pharmacy (SPFO), can help spread trustable information about cancer treatments both to patients and health care practitioners at a local level.

Don’t forget the patient

If the final aim is to be effective and patient-centred, patient involvement is somehow mandatory. With this in mind, the role of patient organizations and patient engagement in the process of improving efficiency in cancer care appear of mainstream importance. “Patient coaching for all medical and non-medical issues could result in a 30% increase in effectiveness and societal savings”, said Stefan Gijssels, Digestive Cancers Europe, Brussels (BE). “A patient supported at all levels during her/his experience with cancer will have better outcomes, and will reach them faster”, he added. However, the current picture of patient involvement is not encouraging. According to a survey on efficiencies, only half of the cancer patients in Europe (53%) feel to be sufficiently involved in making decisions about their care, and information on available peer support groups is not always provided with over two-fifths (41%) of respondents not being informed by their care team. “Patients organizations can have a role in clinical trials and give a valuable contribution to non-medical aspects like sexuality, social interactions, relationships. They should be part of the multidisciplinary team”, Gijssels explained.

The importance of patient engagement has already been recognized by members of the Organization of European Cancer Institutes (OECI), as demonstrated by the launch in 2017 of the Collaboration for Good Practice with Patients (CGPP) working group. “The CGPP motto is: expanding patient Involvement helps cancer centres to increase the quality of care, research and education”, said Patrick Miqueu, CGPP, OECI, Institute Jules Bordet, Brussels (BE), representing OECI at the meeting together with Claudio Lombardo. “Patients can definitely have a role as educators in our future programmes”, Miqueu added, pointing out that patient involvement can be obtained through a close collaboration between cancer centres and patient organizations (Figure 3).

No data (and methods), no science (nor improvements)

Lack of resources and investments is a well-known issue in the oncology field: while the cancer is changing rapidly becoming an increasingly expensive disease, still poor resources are allocated to cancer. “For this reason, we should concentrate our efforts only on what we consider the most important aspects in terms of efficiency”, said Bengt Jönsson, Stockholm School of Economics, Stockholm (SE). “We have to do the things right, but we also have to do the right things”, he added. According to the expert, in modern oncology, health-care professionals and stakeholders can rely on a huge range of alternatives and ways to improve efficiency, but none of them could be implemented without data. “We need reliable data to help doctors make the right choices”, he said. Nevertheless, although extremely important, data are not enough: a methodology is also needed to measure efficacy and to be run by input data on different aspects of efficiency in cancer care. “Efficiency is a measure of the relation between resource use and outcomes. It’s not all about cost savings”, Jönsson pointed out. So, how to properly measure efficiency in cancer care? Data Envelope Analysis (DEA) presented by Jönsson is an example. The methodology calculates efficiency scores based on multiple inputs and multiple outputs, can compare different decision units but also changes during time, and prices are not required to obtain results. Led by the Swedish Institute for Health Economics and unrestricted funding from Bristol-Myers Squibb, a research project aimed at developing a method for studying the efficiency of cancer care provision shown that scores obtained by DEA can identify groups of efficient and inefficient countries. “Data availability will determine what questions can be answered” the expert concluded.

Next (challenging) steps

“Lots of good ideas came out from this long discussion today. The question is now: what are we going to do with them?”, said Matti Aapro, opening the final discussion on the next steps towards the future ESO-SPCC programme on improving efficiency in cancer care. The All.can initiative and its efficiency hub were mentioned as a source of information and examples on the topic, all to be modelled on the characteristics and aims identified by the task-force (Table 1).
“We need to start with a clear, and maybe new, definition of efficiency in cancer care”, Pietro Presti said. “It is better to start small, with a narrowed scope, and then expand our effort trying to tackle the all thing”, echoed Lorenza Wider, SPCC, Munich (DE).
As its final result, the task-force will help structure a training programme to be promoted, rolled out and continuously implemented during a three-year period. The main aim of the project is to scale-up and implement proven concepts for reducing inefficiencies in cancer care, supporting a patient-centric vision and the sustainability of healthcare systems, whilst improving outcomes.
Before that, a position paper and a pilot study will be created to be released in 2020, to clarify ESO-SPCC position on the topic and explore the interest of different stakeholders and actors involved in the cancer care journey, respectively.

Table 1 – What the ESO-SPCC programme should represent

  • A tool to raise awareness on a new culture of efficiency
  • A global (not specific for each professional) and life-long learning (not a one-spot) approach.
  • 
An example of how “thinking out of the box” can improve efficiency, also using innovative approaches/teaching models and a multidisciplinary work.
  • 
A training programme not focused on products but on real needs.

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